Provider Demographics
NPI:1083755037
Name:LEE, MOLLY (OD)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 MIDDLE SCHOOL ROAD
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:TN
Mailing Address - Zip Code:38355
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 MIDDLE SCHOOL ROAD
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:TN
Practice Address - Zip Code:38355
Practice Address - Country:US
Practice Address - Phone:731-664-1604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-11
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN2579152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist